Laurie's Blogs.

Hi Laurie

I am most graciously requesting your input on two cases, if I may. The other will follow in separate email. Please feel free to use it as a case on your blog as you like.

Case: Siu Hak (means black girl- I know, even I can see she is not a black dog!)
1yr, 3mth cross breed (Mongrel), FS. Stray puppy, found with difficulty walking.

Hx: At 4mth old had FHO/FHNE and gr 3 MPL (trochleoplasty, tibial transposition & imbication to LHL. At 5mth same- FHO/FHNE and gr 3 MPL to RHL.
Excellent surgeon. Went well, had UWTM post surgery for some months.
1 year later LHL gr 3 LPL- surgery to imbricate with same surgeon.

Then I am asked to help with improving recovery. My assessment below.....

SUBJECTIVE
Stance: cannot stand w/o muscle movement in her hips and wobbling her HL.
Low top line, hanging tail. Pelvis rotated to LHS, ventrally tilted pelvis.
RH- over extended hock and digits 2-5 hyperextended.  Lateral bowing through the stifle.
LH- Medial bowing of the femur / stifle.  Clubbed toes – really standing on MTs. Dislocation? Collapses when takes weight on this side.
When passing faeces she puts all weight onto front legs, lifting HL from ground. 
 
Gait:
More lame to LHL but unstable rear on both HL. Collapsing to LHL when weight bear. Tends to move both HL together when moving about, including jump up step.
RHS rolls to left when takes weight, L collapses easily under her weight.
FL appear to have normal ROM.
 
Palpation: NERVOUS. difficult to examine as must be held.
LH- Medial bowing of the femur / stifle. 
crepitus with weight bearing as medial collaterals fail to hold.
Stifle has lot of medial buttress from surgery.  Marked decreased bicep femoris.  soft gluteals- little definition here.
Clubbed toes – really standing on MTs. Subluxating MT/P1 of digit 4 + flexor contraction.
 
RH- over extended hock and digits 2-5 hyperextended.  Lateral bowing through the stifle.
Quads are very tight and shortened.  Gluteals are short and fasciculating. Gracilus is overtoned.  Cranial Sartorius sitting medially and pulling her patella proximally and medially.  Sartorius is moderately fibrosed.  R patella is riding medially but can move back into position. Grade II. When in groove then stance is much better.

We are seeing some tiny gains in peanut work (FL support. Hold stifle in correct biomechanical alignment). I feel if the L stifle is supported, then the pelvis is fine but surgeon feels it's due to pelvis collapsing. 
I would like to look at a brace for L stifle but then she does live in a cage in her home with 10 other dogs in their own areas. Surgeon prefers not to brace.
UWTM gives support but if patella luxates and stifle medial collapse then it's difficult to have her extend and start to gait again.
Either way, I appreciate any ideas you may have.

Video links:
walking 1 https://youtu.be/4rKULoxZsbA
walking 2 https://youtu.be/PA8C3xw4lMk
in UWTM https://youtu.be/2j1qFYw_mMw

Thank you for your thoughts.

Kind regards
JM
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Hi Jane,

So, you don't mention whether there is pain or not.  Doesn't really look like a painful walk / stand, more like a weakness walk stand.  You don't say how long she's in the UWT for for conditioning, or the speeds.  But to me it sounds like one of those complicated cases where you have to take your expectations down to a practical level,  and keep it simple, thinking what would make the biggest impact.

So on that note, here are my thoughts:

1) Glutes, Glutes, Glutes!  Proximal / hip stability is a huge factor in controlling the knee (and presumably the stifle - we've seen this clinically in my practice as well). 
    So, the exercises I would use to help this dog would be:
•    1/2 or 3/4 sit to stands - so sitting onto a platform, stool, etc.  There's not enough strength or control to do the whole way... especially as evidenced by how you describe the 'pooping' posture.
•    LOW height 'squat block' step ups.  (See the Training Video: Fun with Cinderblocks):  Front feet on a platform/ stool / block, and one rear leg on another block.  Remaining leg on floor.  Slowly slide that remaining leg away so as to make it awkward for the dog unless she extends the stifle.  Then slowly lower the leg you slid back down to the floor (I put my hand under the paw and push the rump over to that direction and lower).  Gradually, you could increase the height.
•    Backing up might also be warranted as an exercise, and even just some simple cavaletti poles on the floor.
•    I'd have the owners doing some simple 3-leg stands while tapping the glutes, or squeezing the quads to facilitate contractions.  You could do the same, but using e-stim.  The dog needs to work with the e-stim for it to be a targeted exercise.

2) Play with different speeds and water height on the treadmill.  And do it for 15 minutes and build from there.  I don't know how long you're doing it for... but to build muscle and rework muscle memory & patterning, you'll need more challenge and more time.

3) If she's treat motivated, then any directional movement could be good - figure of 8's, side stepping, etc.

4) A brace may be best if ligament compromise is suspected... but she doesn't sound like a great candidate - or rather, her owners don't!  She may very well chew it off if left on unattended.

All in all, sounds like a strengthening issue!  I think if you could get some glutes (and likely that Biceps Fem), it would make a huge impact on the whole of the lower legs / rear end.  I am hesitant to recommend any myofascial work, although she could likely use it, because I doubt she's be relaxed enough and I wouldn't want it to take away from her need to strengthen first and foremost.

Good luck with her!  I hope this helps!

Cheers,
Laurie